ATI RN
ATI RN Custom Exams Set 5
1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?
- A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
- B. The nurse noted unilateral breast enlargement.
- C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
- D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.
Correct answer: D
Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.
2. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?
- A. Notify the healthcare provider
- B. Document that the pericarditis has resolved
- C. Ask the client to lean forward and listen again
- D. Prepare to insert a unilateral chest tube
Correct answer: C
Rationale: The correct action for the nurse to take when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. This position brings the heart closer to the chest wall, making it easier to detect a friction rub if present. Notifying the healthcare provider is not necessary at this point as it may just be a matter of positioning for better auscultation. Documenting that the pericarditis has resolved is premature without proper assessment. Preparing to insert a unilateral chest tube is not indicated based on the absence of a friction rub.
3. The client on furosemide is at risk for which electrolyte imbalance?
- A. Hypokalemia
- B. Hypernatremia
- C. Hyperkalemia
- D. Hyponatremia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with the use of diuretics. Choice B, Hypernatremia, is incorrect as furosemide is not known to cause high sodium levels. Choice C, Hyperkalemia, is also incorrect as furosemide tends to cause potassium depletion rather than excess. Choice D, Hyponatremia, is not directly related to furosemide use.
4. A client is prescribed Ciprofloxacin and seeks guidance from a nurse. Which instruction should the nurse provide?
- A. Take this medication with meals.
- B. Avoid taking this medication with dairy products.
- C. Take this medication at bedtime.
- D. Increase your intake of potassium-rich foods.
Correct answer: B
Rationale: The correct answer is B: 'Avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products due to the interference of calcium with medication absorption. Taking Ciprofloxacin 1 hour before or 2 hours after consuming dairy products ensures optimal effectiveness. Choice A is incorrect because Ciprofloxacin is usually taken on an empty stomach or with a light meal, not necessarily with heavy meals. Choice C is incorrect as there is no specific instruction to take Ciprofloxacin at bedtime. Choice D is incorrect because there is no need to increase potassium-rich foods intake specifically related to Ciprofloxacin use.
5. What is reperfusion injury?
- A. Healing bone tissue after fracture
- B. Skin wound tunneling and shear
- C. Secondary injury after reestablishing blood flow
- D. Injury after blood transfusion
Correct answer: C
Rationale: Reperfusion injury refers to the secondary injury that occurs after blood flow is reestablished following ischemia. This process leads to tissue damage due to the sudden reintroduction of oxygen and nutrients, causing oxidative stress, inflammation, and cell death. Choice A is incorrect as it describes the normal healing process of bone tissue after a fracture. Choice B is incorrect as it describes specific mechanisms related to skin wounds, not reperfusion injury. Choice D is incorrect as it refers to a different concept, which is adverse reactions or complications that can occur after a blood transfusion, not reperfusion injury.